Florida Senate - 2013 SB 896
By Senator Garcia
38-01015-13 2013896__
1 A bill to be entitled
2 An act relating to prepaid dental plans; amending s.
3 409.912, F.S.; postponing the scheduled repeal of a
4 provision requiring the Agency for Health Care
5 Administration to contract with dental plans for
6 dental services on a prepaid or fixed-sum basis;
7 authorizing the agency to provide a prepaid dental
8 health program in Miami-Dade County on a permanent
9 basis; providing an effective date.
10
11 Be It Enacted by the Legislature of the State of Florida:
12
13 Section 1. Subsection (41) of section 409.912, Florida
14 Statutes, is amended to read:
15 409.912 Cost-effective purchasing of health care.—The
16 agency shall purchase goods and services for Medicaid recipients
17 in the most cost-effective manner consistent with the delivery
18 of quality medical care. To ensure that medical services are
19 effectively utilized, the agency may, in any case, require a
20 confirmation or second physician’s opinion of the correct
21 diagnosis for purposes of authorizing future services under the
22 Medicaid program. This section does not restrict access to
23 emergency services or poststabilization care services as defined
24 in 42 C.F.R. part 438.114. Such confirmation or second opinion
25 shall be rendered in a manner approved by the agency. The agency
26 shall maximize the use of prepaid per capita and prepaid
27 aggregate fixed-sum basis services when appropriate and other
28 alternative service delivery and reimbursement methodologies,
29 including competitive bidding pursuant to s. 287.057, designed
30 to facilitate the cost-effective purchase of a case-managed
31 continuum of care. The agency shall also require providers to
32 minimize the exposure of recipients to the need for acute
33 inpatient, custodial, and other institutional care and the
34 inappropriate or unnecessary use of high-cost services. The
35 agency shall contract with a vendor to monitor and evaluate the
36 clinical practice patterns of providers in order to identify
37 trends that are outside the normal practice patterns of a
38 provider’s professional peers or the national guidelines of a
39 provider’s professional association. The vendor must be able to
40 provide information and counseling to a provider whose practice
41 patterns are outside the norms, in consultation with the agency,
42 to improve patient care and reduce inappropriate utilization.
43 The agency may mandate prior authorization, drug therapy
44 management, or disease management participation for certain
45 populations of Medicaid beneficiaries, certain drug classes, or
46 particular drugs to prevent fraud, abuse, overuse, and possible
47 dangerous drug interactions. The Pharmaceutical and Therapeutics
48 Committee shall make recommendations to the agency on drugs for
49 which prior authorization is required. The agency shall inform
50 the Pharmaceutical and Therapeutics Committee of its decisions
51 regarding drugs subject to prior authorization. The agency is
52 authorized to limit the entities it contracts with or enrolls as
53 Medicaid providers by developing a provider network through
54 provider credentialing. The agency may competitively bid single
55 source-provider contracts if procurement of goods or services
56 results in demonstrated cost savings to the state without
57 limiting access to care. The agency may limit its network based
58 on the assessment of beneficiary access to care, provider
59 availability, provider quality standards, time and distance
60 standards for access to care, the cultural competence of the
61 provider network, demographic characteristics of Medicaid
62 beneficiaries, practice and provider-to-beneficiary standards,
63 appointment wait times, beneficiary use of services, provider
64 turnover, provider profiling, provider licensure history,
65 previous program integrity investigations and findings, peer
66 review, provider Medicaid policy and billing compliance records,
67 clinical and medical record audits, and other factors. Providers
68 are not entitled to enrollment in the Medicaid provider network.
69 The agency shall determine instances in which allowing Medicaid
70 beneficiaries to purchase durable medical equipment and other
71 goods is less expensive to the Medicaid program than long-term
72 rental of the equipment or goods. The agency may establish rules
73 to facilitate purchases in lieu of long-term rentals in order to
74 protect against fraud and abuse in the Medicaid program as
75 defined in s. 409.913. The agency may seek federal waivers
76 necessary to administer these policies.
77 (41)(a) The agency shall contract on a prepaid or fixed-sum
78 basis with appropriately licensed prepaid dental health plans to
79 provide dental services. This paragraph expires October 1, 2017
80 2014.
81 (b) Notwithstanding paragraph (a) and for the 2012-2013
82 fiscal year only, the agency may is authorized to provide a
83 Medicaid prepaid dental health program in Miami-Dade County. For
84 all other counties, the agency may not limit dental services to
85 prepaid plans and must allow qualified dental providers to
86 provide dental services under Medicaid on a fee-for-service
87 reimbursement methodology. The agency may seek any necessary
88 revisions or amendments to the state plan or federal waivers in
89 order to implement this paragraph. The agency shall terminate
90 existing contracts as needed to implement this paragraph. This
91 paragraph expires July 1, 2013.
92 Section 2. This act shall take effect June 30, 2013.